EVIDENCE BASED TREATMENT OF PMADS - PREGNANCY & POSTPARTUM SUPPORT MN - 2022 June 9
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PREGNANCY & POSTPARTUM SUPPORT MN
EVIDENCE BASED
TREATMENT OF PMADS
2022 June 9 Full Name For all purpose
The Board of Directors for Pregnancy &
Postpartum Support Minnesota (PPSM) represents
mental health therapists, doulas and community
members that are passionate about spreading
awareness of perinatal mood and anxiety
disorders, and engaging the professional
community across the state of Minnesota.
Many of us have personal experiences connected
to perinatal mental health.
The Board seeks to affirm the four pillars below
as a means to engage the community we serve:
• Support
• Advocacy
• Awareness Mandy Wannarka, MSW, LICSW, PMH-C, RYT-200
• Training Executive Director
Pregnancy & Postpartum Support Minnesota (PSI-MN)
2
ABOUT PPSM
PPSM's mission is to engage Minnesota parents
and professionals in promoting optimal emotional
well-being during pregnancy and the postpartum
period.
We affirm the vision of Postpartum Support
International (PSI)
• To establish a prenatal support network in
every community worldwide
• Increase public awareness
• Train multidisciplinary perinatal professionals
• Support public health policy initiatives
3
FOLLOW US ON SOCIAL MEDIA
• Facebook - Pregnancy and Postpartum Support Minnesota
⚬ business page + closed community support group
• Instagram
⚬ @ppsupportmn
• Podcast "PPSM baby Brain" https://feeds.buzzsprout.com/1483933.rss
3
National Support through PSI
postpartum.net
1 Provider directory
2 Virtual Support Groups
3 Chat with the experts
4 PSI 2 day training, advanced
trainings and Certification
LEARNING OBJECTIVES
• Define & Identify Perinatal Mood and Anxiety Disorders
(PMADs)
• Explain the advantages of early identification
• Name risk factors for developing PMADs and special
population considerations
• Identify 3 Therapeutic Treatment Approaches and
Community Resources to support those with PMADs
2
The Crisis of
Parenthood
ALL new & expectant parents need
support & information
Parenting in the Our villages are limited
Between working and living farther away from families, many new
21st Century parents find themselves figuring out how to raise kids alone, without
day to day support of family, friends or neighbors.
Expectations are high but supports are
non-existant for many
Paid maternity or paternity leave is rare and usually only for the upper
class, health insurance costs are sky high, as is everything else and
daycare often costs more than a mortgage.
Global Events Haven't Helped Anything
A global pandemic made worse by political upheavil, coupled with the
increase in racism, violent crime and war has led many to fear for their
safety both personally and as a civilization
Perinatal Mood and Anxiety
Disorders (PMADs)
Perinatal Mood &
Encompass pregnancy through
Anxiety Disorders
one year postpartum
(PMADs)
Underdiagnosed
Multifactorial
Can arise at key hormonal shifts but
are NOT just about hormonesUnderstanding Symptoms
• Symptoms can occur within pregnancy • 50% of women with symptoms go undetected.
and the first 12 months postpartum; (Barrera et. al., 2015)
⚬ Most frequent onset times are in the
3rd trimester and first 6 weeks • 5 – 20% of women experience their first episode
postpartum. of anxiety or depression during the perinatal
period. (Meltzer-Brody, 2017)
• Can be difficult to separate typical
• Can extend beyond first year if untreated/recur
adjustment symptoms such as fatigue
in subsequent pregnancy.
and overwhelm from clinical PMADs
without deeper questioning.Barriers to Lack of routine screening
Identification and
Treatment Cultural stigma
Finances and insurance
Community resources
Provider unsure of correct
resourcesUntreated PMAD Effects on Pregnancy/ Fetal Development • Pre-term labor and premature birth • Placental abruption • Growth restriction • Low birth weights https://doi.org/10.9740/mhc.n163635
Effects of Untreated PMADs on the Birthing Parent Postpartum • Poor eating, sleeping, and self care • Less likely to seek medical care postpartum • Relationship strain • Impacts on self esteem and confidence • Substance abuse risk increases
Untreated PMADs
Effects on Parenting
• Poor maternal-child bonding/attachment
• Interactions with infant/child are less
positive
• Infants receive less cognitive
stimulation, modeling of effective
problem solving and emotional
regulation
• Responses are more punitive (reis.
2001)
• Higher risk of abuse and neglect
(NICHD Early Child Care Research Network. 1999 )https://doi.org/10.9740/mhc.n163635• “This doesn’t feel like me”/”not what I
expected” = failure
• Agitation or rage- not crying
• “Better off without me”; “escapist fantasies” vs.
Perinatal Specific wish to die
Symptoms: • Lack of feelings/connection with baby
• Thoughts of not being good for baby
Depression (1 in 5)
• Thoughts of harm to baby
• Not attending to baby's needs
• Not responding to baby's cries
• Not showing affection toward baby
• Thoughts of escaping from baby/familyBaby Blues vs Depression
Baby Blues Postpartum Depression
Timeframe: first 2 weeks after birth Timeframe: symptoms occur most days, nearly
Symptoms include changes in mood in response everyday for 2 weeks or more
to stressors, feeling overwhelmed, irritable or Symptoms include mood that is flat, sad or irritable
annoyed easily with anger being common
Generally resolve when the stressor resolves Changes in sleep, appetite and energy
Still able to laugh, see the bright side of things, Persistent guilt and/ or shame
feel positive emotions Thoughts or suicide or running away from current life
Change in stressors don't improve or shift mood much• Excessive concern about baby’s or parent's
own health
• Fears of baby not breathing
Perinatal Specific • Fear of falling, dropping or hurting baby
• Fear others will harm or take the baby
Symptoms:
• Overcontrolled/rigid thinking or behaviors
Anxiety (1 in 7) regarding feeding and/or sleep
• Pressure to be "Super Mom"
• High achieving are women more likely to have
anxiety/OCD than depression.
• Very commonly comorbid with PPD
(Ramakrishna, 2019)• Intrusive, repetitive thoughts – usually of harm
coming to the baby
• (ego-dystonic – meaning the thoughts do not
Perinatal Specific fit with the mother’s values or personality)
Symptoms: • Tremendous guilt and shame related to
OCD (3 to 11%) thoughts
(Sharma, 2019) • Parent feels horrified by the thoughts
• Parents engage in behaviors to avoid harm or
minimize triggers
• Often leads to depressive episode
Educate parents that THOUGHTS DO NOT EQUAL ACTIONSPostpartum PTSD (3-15%)
(Cirino & Knapp, 2019)
• PTSD symptomology, often caused by:
⚬ Struggles with infertility
⚬ Traumatic birth experiences (40%, Ginicola & Kish, 2016)
￭ Unwanted interventions Trauma is in the eye
￭ Medical complications
￭ Separation from baby of the beholder.
￭ Not being heard, feeling mistreated
⚬ NICU admissions (25%, Malin, et al, 2020)
⚬ Stillbirth or infant death Cheryl Beck, CNM
⚬ Previous history of sexual abuse or assault
⚬ History of previous trauma• Symptoms can look like anxiety or severe
depression
• Reduced need for sleep rather then racing thoughts
preventing sleep (typical in anxiety)
Perinatal Specific • Disorganization, may have difficulty prioritizing steps
Symptoms: in self care and/or care of baby
Bipolar • May present with severe depression rather then in
times of mania or hypomania
• Extra caution with a personal history of/ or first
degree relative with bipolar disorder ANY
prolonged period of sleep disturbance should be
met with urgent intervention to treat sleepPostpartum Psychosis
(1 to 2 in 1,000)
• Rational acts are committed for irrational Naomi Gaines, St. Paul,
2003
reasons; psychosis prevents mother from
understanding the irrationality. “Logic that is
illogical.”
Andrea Yates, TX, 2001
• Of the 1 in 1,000:
⚬ 5% die by suicide
Shwe Htoo, St. Paul, 2017
⚬ 4% commit infanticide
• Onset is usually within the first 3 weeks
postpartum (usually 3-5 days)Perinatal Specific Symptoms
• Delusions (e.g. baby is possessed by a demon)
• Hallucinations (e.g. seeing someone else’s face instead of baby’s face)
• Confusion/disorientation
• Out of touch with reality – strange thoughts seem normal to them
• Rapid mood swings
• Waxing and waning – can appear and feel “normal” in between psychotic symptom
episodes
Postpartum.ne
tPMADs and Partners (8-10%)
• 1 in 10 partners experience PMADs
• Symptoms occur later in comparison to birthing person
• Higher risk for those with a partner who has a PMAD- 50%
• Symptoms look different for males
• Increased tension/ irritability
• Fears which may be different than the birthing parent
• Substance use
• Feeling helpless, like they can't do anything right
• Avoidance (overworking, staying away from home)
• Worries which may be expressed in trying to control or "fix"Partners Experience Stigma
• More likely to die by suicide in a lethal manner
• Less likely to ask for help
• Approach may need to be different
• Medication vs therapy
See if you can encourage the partner to attend at least one
check up postpartum to get eyes on them too!Risk Factors Checklist for PMADs
Many new parents say, “I wish I had known I was at risk”.
Predisposing Factors: Postpartum Factors:
• History of severe PMS/PMDD or mood changes • Chronic health conditions, chronic pain, or
when taking birth control change in health due to pregnancy (pain, injury,
• Personal or family history of mental health etc.)
disorders, chemical dependency or eating • Traumatic birth/loss
disorder. • Hormonal shifts - taking birth control,
• Social/Environmental stressors- job loss, lack discontinuing breastfeeding
of support, financial strain, etc. • Difficult infant temperament/Baby with health
• Marital/Relationship stress complications
• Unplanned or complicated pregnancy • Premature delivery/NICU involvement
(hyperemesis, loss, difficult diagnosis, • Breastfeeding difficulties
infertility). • Having multiples (twins, triplets or more)
• Teen pregnancy • Sleep deprivation
• History of previous trauma(s) (abuse, exposure
to violence, pregnancy loss, veterans, etc.)
https://ppsupportmn.org/pmad-resources-handouts-moms/
• “Type A” personalityRisk Factors: Sexual Minorities • Limited research compared to cis-gendered heterosexual individuals • Increased financial and legal stressors • Lack of inclusive resources and materials • Fewer social supports and higher rates of rejection from community (family, faith, general support) • Discrimination within healthcare systems • Higher rates of IPV, harassment, abuse or violence • Struggles with infertility • Reduced access to care overall but especially around options to build a family • Experience higher rates of grief and distress from the impact of all of the above
Increased risk of Postpartum Depresion
Lesbian Women - higher prevalence of PPD, being
treated for depression, attempting and considering
suicide in postpartum period (Maccio, 2011) "People talk about the attention you get when
you're pregnant, and for the most part that was
absent for me" he said.
Gay Parents- less positive feeling at the end of
pregnancy than lesbian mothers and more positive No one rubbed his belly, asked when he was due
or commented that he was carrying the baby
feelings about parenthood during the first postpartum low so it must be a boy.
weeks than heterosexual parents (Rubio, 2017)
"Mostly I liked that, because I don't like body
attention normally," he added,
Bisexual Women- increased risk of PPD if currently "but there's also a loss."
partnered with man vs. woman (Flanders, 2016)Cultural Considerations for Parents of Color
• Rates of postpartum depression in women of color 38%
⚬ maternal mortality rates higher (and the gap is growing)
• 60% of women of color do not receive mental health services
⚬ less likely to initiate treatment in comparison to white women
• Beliefs about mental health, access to multi-cultural
resources/supports
Practitioners must take responsibility for becoming proficient in the recognition of the cultural
context of psychological symptoms and its effects on women of color.
(Kozhimannil et al.,
2011)Incidence of substance use in pregnancy
5.9% 8.5% 15.9%
drugs alcohol cigarettes
2016 Forray, F1000Research nih.govBarriers to Care • Lack of identification of pregnancy • Lack of identified/disclosed substance use • Fear of consequences for substance use • Lack of knowledge about treatment options • Lack of access to specialized care • Fear of peer criticism
Treating PMADs
Options for Treatment
“Traditional” Approaches: "Alternative" Approaches:
• Counseling • Acupuncture
• Energy work (e.g. Reiki)
• Medication
• Light therapy
• Exercise/movement
• Chiropractic/massage
• Support/therapy groups • Mindfulness/meditation
• Church/faith community • Nutrition/vitamins
• Placenta Encapsulation
• Medical Doctor
• Essential oils
⚬ (rule-out underlying medical causes)
• Yoga/pilates
• Somatic workPsychotherapy • Interpersonal Therapy (IPT) • Cognitive Behavioral Therapy (CBT) • Mindfulness based Therapies (ACT & DBT) • Eye Movement therapies ⚬ (EMDR, ART & Brainspotting) • Couples therapy • Family therapy • Group therapy
Intervention, Referral & Follow-up • Talking about PMADs IS an intervention • You are an important supporter, advocate, & ambassador in parent’s life • Ask what their resources are ⚬ Get them thinking about the help they may already have available • If you are worried about someone, say it • If for any reason you don’t feel they are safe, seek assistance ⚬ Connect with your supervisor, the parent's family, doctor, 911 • Don’t keep it secret!
Intervention, Referral & Follow-up • If you suspect or discover PMAD symptoms: be direct about the need for help • List the possibilities: doctor, therapist, support group, etc. • Provide phone numbers of local resources • Help the parent make the appointments • Call their doctor’s office for them; describe symptoms to nurse
PPSM
OUTREACH
• Postpartum Doula Program
• Community resources on website
• Newsletters for parents + professionals
• 1:1 Peer Support
• Parent and professional events
• Baby Brain podcast
3Additional Resources • PSI's Directory: https://psidirectory.com/ • PSI's Virtual Support Groups: https://www.postpartum.net/get- help/psi-online-support- meetings/ • PSI Dad's Chat 1st Monday/Month
Citations Alang, S. et al (2014). Postpartum Depression in an online community of lesbian mothers: implications for clinical practice. Journal of Gay & Lesbian Mental Health. 19(1), 21-39. Augustine, J. et al (2017). Are the parents alright?: time in self-care in same-sex and different-sex two-parent families with children. Population Review, 56(2). doi:10.1353/prv.2017.0007 Bouman, W. et al (2016). Transgender and anxiety: a comparative study between transgender people and the general population. International Journal of Transgenderism, 18(1). 16-26. Chapman, R. et al (2012). A descriptive study of the experiences of lesbian, gay and transgender parents accessing health services for their children. Journal of Clinical Nursing, 21(7-8). 1128-1135. Charlton, B. et al (2018). Teen pregnancy risk factors among young women of diverse sexual orientations. Pediatrics, 141(4). Charter, R. et al (2018) The transgender parent: experiences and constructions of pregnancy and parenthood for transgender men in Australia. International Journal of Transgenderism, 19(1). 64-77. Cote, I & LaVoie, K. (2018). A child wanted by two, conceived by several: lesbian-parent families negotiating procreation with a known donor. Journal of GLBT Family Studies, DOI: 10.1080/1550428X.2018.1459216 Ellis, SA et al (2015). Conception, pregnancy and birth experiences of male and gender variant gestational parents: it’s how we could have a family. Journal of Midwifery & Women’s Health, 60(1). 62-69. Erickson-Schroth L., Glaeser E. (2017) The Role of Resilience and Resilience Characteristics in Health Promotion. In: Eckstrand K., Potter J. (eds) Trauma, Resilience, and Health Promotion in LGBT Patients. Springer, Cham. 51-56. Everett, B. et al (2017). Sexual orientation disparities in mistimed and unwanted pregnancy among adult women. Perspectives on Sexual and Reproductive Health, https://doi.org/10.1363/psrh.12032 Flanders, C. et al (2015). Postpartum depression among visible and invisible sexual minority women: a pilot study. Archives of Women’s Mental Health, 19(2). 299-305.
Citations Hopping-Winn, A. (producer, 2018). Supporting LGBT Families in the Postpartum Period, welcomebaby.labestbabies.org James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The Report of the 2015 U.S. Transgender Survey. Washington, DC: National Center for Transgender Equality. James-Abra, S. et al. (2015). Trans people’s experiences with assisted reproduction services: a qualitative study. Oxford Academic Human Reproduction, 30(6). 1365-1374. Jindarak, S. et al (2018). Spermatogenesis abnormalities following hormonal therapy in transwomen. Biomed Research International, 2018. Article ID 7919481, 5 pages. Maccio, E. & Pangburn, J. (2011). The case for investigating postpartum depression in lesbians and bisexual women. Women’s Health Issues, 21(3). 187-190. Ressler, I. et al (2014). The road to fatherhood using assisted reproductive technology: decision making processes and experiences among gay male intended parents and gestational surrogates. Gynecology and Obstetrics Research, 1(1). 12-17. Rubio, B. et al (2018). Transition to parenthood and quality of parenting among gay, lesbian and heterosexual couples who conceived through assisted reproduction. Journal of Family Studies, DOI: 10.1080/13229400.2017.1413005. Wierckx, K. et al (2012) Reproductive wish in transsexual men. Human Reproduction, 27(2). 483-487.
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